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Content ArticleIn this briefing paper for the Social Market Foundation, Lord Norman Warner sets out a radical change programme that could reverse the decline in NHS services. It examines long-term issues that have been exacerbated by the impact of Brexit and the Covid-19 pandemic—the care backlog, workforce issues and loss of public confidence.
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Content ArticleIt is important that patients understand the risks, benefits and alternatives associated with their treatment, but there is often a gap in patients' actual understanding of these issues. There is now substantial evidence showing that patient decision aids (PDAs) and shared decision making can bridge the gap between the theory and practice of informed consent. However, in spite of the evidence, PDAs are still rarely used in clinical settings. This article in the journal Maine Law Review looks at how the monetary incentive of a professional liability insurance premium reduction could encourage doctors in the USA to increase the use of PDAs.
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Content ArticlePatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
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Content ArticleHealthcare is traditionally a hierarchical industry. This structure can foster a culture of division amongst staff that is sometimes made worse by significant differences in background and training. However, in order to make sure care is safe and of a high quality, healthcare teams must develop good teamwork and communication. This is only possible if every member of the team feels respected and is free to speak up when they think something is wrong. In this podcast, host David Feldman speaks to Michael Brodman, Professor and Chair Emeritus in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai in the US. They discuss how mutual respect is essential for any institution developing a culture of safety and how the problems presented by medical hierarchy can be overcome.
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Content ArticleThis blog by doctors Clare Rayner and Amali Lokugamage argues that Long Covid rehabilitation needs a wider focus that goes beyond a purely biomedical paradigm to include complementary therapies and methods. The authors—who have both lived with Long Covid for more than two years—argue that although patients were the first to raise concerns about Long Covid, describe its symptoms and patterns and even research the condition, their narratives and voices are not being included in approaches to treatment. While the biomedical evidence surrounding Long Covid is currently limited, they highlight that there is much valuable lived-experience to be found in patient support and campaign groups, and that patients' knowledge should be drawn on to shape policy and guidance about the condition.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Clive talks to us about the important role of digital technologies in tackling the big issues healthcare faces, the need for digital tools and records to be joined-up and interoperable, and how his experiences as a carer have shaped how he sees patient safety. -
Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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Content ArticleThis blog by the charity Mental Health UK looks at an innovative project that aims to transform the way care and support are delivered to people living with severe mental illness in Grimsby and Bridgend. It aims to meet people’s mental health needs by providing tailored support, signposting them to specialist services to improve their quality of life, prevent the need for emergency crisis care and reduce pressure on acute medical services. The project is being run in conjunction with healthcare company Johnson & Johnson UK, with the support of the local NHS. The project involves Community Mental Health Navigators supporting the non-medical needs of people living with severe mental illness, such as bipolar disorder, schizophrenia and borderline personality disorder. They provide support with aspects of people’s lives which can drive poor mental health, such as housing, money problems, employment, physical wellbeing and lack of social connections.
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Content ArticleThis online community has been set up by the Care Quality Commission (CQC) to engage with members of the public on a range of topics related to the CQC's work as regulator of health and social care services in the UK. The site invites people to get involved in different ways, for example: by sharing expertise, experience and thoughts through discussions. by reviewing documents. by taking part in polls and surveys. by contributing to idea boards. When signing up, you can either use your own name or your organisation’s name, and you'll be asked to choose what groups you represent and what sectors you work in or use.
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Content ArticleIn this blog, Dr Chloe Stewart, health psychologist and national clinical advisor in personalised care for NHS England, looks at the role of personalised care in helping overcome the care backlog and addressing health inequalities in people with musculoskeletal conditions (MSKs). She looks at examples of coproduction in MSK services and highlights the need to give patients better information and training about how to manage their condition.
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EventuntilEntrenched health inequalities have come to the fore over the past couple of years and we have seen some of the sharpest declines in health and wellbeing for our children, young people and their families. Never has there been a more urgent need to address the link between wider social, economic and environmental causes to the increased risk of poor public health and mental health. These are best understood and addressed at a local level by people and organisations that have relationships and knowledge of the nuances and cultures of individuals and communities. The formation of Integrated Care Systems (ICSs) represents a significant opportunity for Boards to engage the voluntary, community and social enterprise (VCSE) sector in order to enable a truly integrated Health and Social Care System to be delivered. These new arrangements which will bring together local system partners should serve to strengthen relationships between the NHS and VCSE sector and promote greater equity. This free webinar, co-produced and sponsored by Barnardo’s, brings together an esteemed panel of experts to discuss how we make the most of these opportunities at this critical time, as well as showcasing innovative VCSE projects that are delivering improved outcomes for children, young people and their families. Register for the webinar
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Content ArticleThis study in the journal Current Problems in Diagnostic Radiology aimed to explore the perspectives of radiology and internal medicine residents on the desire for personal contact between radiologists and referring doctors, and the effect of improved contact on clinical practice. A radiology round was implemented, in which radiology residents travel to the internal medicine teaching service teams to discuss their inpatients and review ordered imaging. Surveys were given to both groups following nine months of implementation. The vast majority of both diagnostic radiology residents and internal medicine residents reported benefits in patient management from direct contact with the other group, leading the authors to conclude that this generation of doctors is already aware of the value of radiologists who play an active, in-person role in making clinical decisions.
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Content ArticleMedication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
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Content ArticleThis realist evaluation aimed to explore and explain the ways in which a programme initiated by the Scottish Government, Keeping Childbirth Natural and Dynamic (KCND), worked or did not work in different maternity care contexts. KCND was a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.
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Content ArticleThis mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.
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Content ArticleThis study presents the findings of ‘The concept of seriousness in fitness to practise’ project commissioned by the General Dental Council (GDC) and the Nursing and Midwifery Council (NMC). The project took place between December 2019 and September 2021 and investigated how seriousness in Fitness to Practise (FtP) cases is understood and applied by health professions regulators. The research aimed to: develop an understanding of how the concept of seriousness in relation to misconduct is defined and applied by professional regulators, and to identify the considerations that influence that application. achieve a clearer understanding of the similarities and differences in approaches across regulation and reasons for these. describe the relationship between professional misconduct, enforcement actions and the statutory objectives of healthcare regulation.
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Content ArticleThis paper in the journal Learning Health Systems examines what would be needed to develop learning health systems (LHS) in the United Kingdom, considering national policy implications and actions which local organisations and health systems could take. It identifies opportunities for local NHS organisations to make better use of health data and ways that national policy could promote greater use of collaboration and analytics.
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Content Article
Blog - When diabetes devices fail (8 December 2020)
Patient-Safety-Learning posted an article in Diabetes
In this article for US magazine Consumer Reports, Rachel Rabkin Peachman looks at the incidence and impact of malfunctions and design flaws in continuous blood glucose monitors, insulin pumps and other diabetes equipment. She highlights the case of Pamela, a 64-year-old with diabetes who died when her insulin pump unintentionally gave her a massive dose of insulin overnight. The numbers of adverse events and deaths reported to the FDA regarding diabetes devices is far greater than for any other type of medical device—between January 2019 and July 2020, almost 400 deaths and 66,000 injuries in the US were linked to commonly used diabetes devices. Reports are spread across the different device manufacturers and demonstrate the complexities of trying to determine the exact cause of each adverse event. The article also includes information on how people with diabetes can protect themselves from device malfunctions and errors. -
Content ArticleClosed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
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Content ArticleThis blog by management consultancy McKinsey & Co looks at how to harness the power of people with informal influence to enact transformation within an organisation. It explores a tool known as 'snowball sampling', a simple survey technique originally used by social scientists to study hidden populations reluctant to participate in formal research, such as street gangs, drug users and sex workers. In snowball sampling, recipients take a very short survey and are asked to identify acquaintances who should also be asked to participate in the research. The process instils trust in participants as referrals are made anonymously by peers rather than through formal identification, and one contact quickly snowballs into many. The blog explores how snowball sampling can be adapted to better understand the patterns and networks of influence that operate below the radar in an organisation.
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Content ArticleOver the past few years, concerns have been raised about the level of funding and intervention regulators have received from the pharmaceutical industry. In this article for The BMJ, investigative journalist Maryanne Demasi examines whether regulators of medical devices and medications have enough independence from the companies they are meant to regulate. She asked six of the world's biggest regulators about their funding and transparency and found that industry money permeates the world's leading regulators. This casts doubt on their ability to provide effective regulation, especially in the wake of a string of drug and device scandals.
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Content ArticleThis article in The Milbank Quarterly summarises an extensive literature review addressing the question, "How can we spread and sustain innovations in health service delivery and organisation?" The authors identify three key outputs of the systematic review: A parsimonious and evidence-based model for considering the diffusion of innovations in health service organisations Clear knowledge gaps on which further research on the diffusion of innovations in service organisations should be focused A robust and transferable methodology for systematically reviewing complex research evidence
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Content ArticleThe government has published a draft Mental Health Bill for pre-legislative scrutiny. The bill aims to modernise the Mental Health Act for the 21st century.
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Content Article
UK Covid-19 Inquiry Terms of Reference (28 June 2022)
Patient-Safety-Learning posted an article in Covid-19 Inquiry
This document outlines the final terms of reference for the Public Inquiry into the government's response to the Covid-19 pandemic, chaired by Baroness Heather Hallett. The Inquiry will examine, consider and report on preparations and the response to the pandemic in England, Wales, Scotland and Northern Ireland. Baroness Hallett has also recorded a video statement to the public about the Inquiry, which includes a British Sign Language translation. -
Content ArticleThis blog by the charity Picker explores concerns about the safety of staffing levels in the NHS, highlighted by the 2021 NHS Staff Survey. It talks about the potential impact of a recent drop in staff morale. The blog draws out these key findings from the survey: The proportion of staff who felt unwell as a result of work-related stress in the last 12 months rose to 46% – almost half. This was an increase of nearly 3% from the 2020 figure (44%) and continued a trend: the figure has risen each year since 2017, when 38% of staff reported work-related stress. Almost one-in-three staff members say they “often think about leaving” their organisation – an increase of 4% points vs the 26% recorded in 2020. And one-in-six (16%) say they will leave their organisation “as soon as I can find another job” – a 2% point increase from 2020. Only 52% of NHS staff say that they look forward to going to work – a decline of more than 6% points from 58% in 2020. New questions in the survey suggest that many staff are experiencing burnout. Overall, more than a third of staff (34%) said that they ‘always’ or ‘often’ “feel burnt out because of [their] work”. The proportion was even higher for staff in patient facing roles (for example, 41% of registered nurses and midwives) and especially for ambulance personnel (51%).
